c-1 charting formweb1.dent.cmu.ac.th/mis/dis/userfiles/file/general/2019/...clinical examination:...
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C-1 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
INFORMED CONSENT
วันที่...................... เดือน.................................... พ.ศ.................................
หนังสือฉบับนีเ้ป็นหลักฐานแสดงวา่
ข้าพเจ้า (นาย / นาง / นางสาว) ........................................................................... อายุ ............. ปี สัญชาติ...............
ในฐานะเป็น (ผู้ป่วย/ผู้มีอ านาจกระท าแทน) เกี่ยวข้องเป็น .........................ของผู้ป่วย ขอแสดงความยินยอมให ้
นักศึกษาทันตแพทย์ ที่ เข้าฝึกปฏิบัติงานในคลินิกทันตกรรมพร้อมมูล สาขาวิชาทันตกรรมทั่วไป ภาควิชา
ทันตกรรมครอบครัวและชุมชน คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ ท าการรักษาทางทันตกรรมพร้อมมูล
รวมทั้งการฉีดยาชาเฉพาะที่เพื่อประโยชน์ในการรักษา ภายใต้การควบคุมดูแลโดยอาจารย์ทันตแพทย์ หรือ ทันตแพทย์
และหากเกิดความเสียหายใดๆ อันเป็นผลแทรกซ้อนซึ่งเป็นเหตุสุดวิสัยที่เกิดจากการรักษาตามหลักวิชาการ หรือ
การฉีดยาชาเฉพาะที่ดังกล่าว จะไม่เรียกร้องสิทธิใดๆทั้งสิน้ตามกฎหมาย
ข้าพเจ้า ได้รับการอธิบายให้เข้าใจเป็นอย่างดีเกี่ยวกับการรักษาทางทันตกรรมพร้อมมูล การวินิจฉัยโรค
แผนการรักษาทางทันตกรรม การรักษาทางเลือก ค่ารักษา ความเสี่ยงและภาวะแทรกซ้อนที่อาจจะเกิดขึ้น
จากการรักษาทางทันตกรรม
ข้าพเจ้า ยินดีให้ใช้ข้อมูลการรักษาทางทันตกรรมของข้าพเจ้า เพื่อเป็นประโยชน์ทางด้าน งานวิชาการ และ
การเรียนการสอน
ท่านมีสิทธิ์สมบูรณ์ที่จะตัดสินใจยินยอมหรือไม่ยินยอมรับการรักษาทางทันตกรรมพร้อมมูล และให้ท่านลง
ลายมอืชื่อเพื่อเป็นส่วนหน่ึงของหลักฐานประกอบกระบวนการขอความยินยอมในการรักษา
(ลงช่ือ)....................................................................... ผูป้่วย หรือ ผู้มีอ านาจกระท าแทน
(......................................................................)
(ลงช่ือ)....................................................................... อาจารย์ / ทันตแพทย์
(......................................................................)
(ลงช่ือ)....................................................................... พยาน
(......................................................................)
C-2 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Personal data
Name: ______________________________________________ Age: ___________ Sex: male female
Status: Single Married Divorced Widowed Occupation: __________________ Date of birth: _____________
Address: _____________________________________________________________________________ Zip code: _____________
Home phone: _____________________ Personal phone: _____________________ E-mail: _____________________________
Emergency contact person : ______________________________ Relation: ____________ Phone: ________________________
Date:_______________________ BP ________________ mmHg HR ______________ bpm
Chief complain: _________________________________________________________________________________________________
Medical History
Do you have or Have you had …?
Heart problem
Lung disease
Anemia
GI disease
AIDS
Jaundice
Bleeding disorder
Liver disease
Arthritis
Skin disease
Cancer or Tumor
Injury
High blood pressure
Kidney problem
Joint disease
Venereal disease
Chemotherapy
Diabetes mellitus
Thyroid disorder
Asthma
Rheumatic fever
Radiotherapy
Any other diseases ____________________________________________________________________________________________
Taking medicine ______________________________________________________________________________________________
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Allergic to (Drugs, medicines, substances) ________________________________________________________________________
Habit (smoking, alcohol consumption, bruxism) ____________________________________________________________________
Present Illness __________________________________________________________________________________________________
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Dental History
Frequency of dental visit every 3 month every 6 month every 1 year _______________________
Past dental history
Oral ulceration
TMJ sound or Pain
Complication following dental treatment
Xerostomia
Past jaw or facial injury
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Abnormal Bleeding
Reaction to local anesthesia
Past dental work Restoration Extraction Prosthetic treatment Periodontal treatment
Endodontic treatment Oral medicine TMD Other ___________________________
Additional comments ___________________________________________________________________________________________
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MEDICAL ALERT _____________________________
ALLERGIC TO _____________________________
C-3 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Clinical examination: Extraoral examination
Front view Symmetrical Asymmetrical Profile form Ovoid Round Square Taper
Lateral Profile Concave Straight Convex
TMJ examination Click : R / L Pain : R / L Deviation : R / L Crepitation : R / L
Dislocation : R / L Overjet: _________ Overbite: ___________ Others : _____________________
Clinical examination: Intraoral examination
Soft tissue examination
Examination report: ________________________________
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Calculus : Slight Moderate Heavy Halitosis : No Yes
High muscle attachment : No Yes : ___________________ Tooth form : Taper Ovoid Square
Occlusion : _____________________________________________________________________________________________________
Occlusal trauma : No Yes : _____________________ Torus / Exostosis : No Yes : _______________________
Oral hygiene : Good Fair Poor Brush type : __________________ Dentifrice : __________________
Technic : __________________ Frequency : ______________ Oral hygiene aids : ___________________________________
Oral habits : Clenching Grinding Bruxing Lip biting Cheek biting
Tongue thrusting Mouth breathing Tooth picking _______________________________
Patient attitude : Good Fair Poor
Overall Prognosis : Good Fair Questionable Poor Hopeless
Tooth contact analysis
MIP / CR 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Protrusion 8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Left
Excursion
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
Right
Excursion
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8
C-4 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Periodontal Diagnosis ________________________________________________________________________
Pain on percussion:
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Tooth mobility
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Traumatic occlusion
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Malposed tooth
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Oral habits:
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การใช้สัญลักษณ ์(symbols)
M : missing
U : unerupted tooth
PE : partial eruption
OE: over eruption of tooth
I : Extracted
การระบายสี (draw)
cavities : blue
filling/RCT/post & core: black
crown/pontic : yellow
gingival margin : green line
pocket depth : red line
Furcation involvement
grade I
grade II
grade III
Bleeding index =_________%
Clinical attachment loss:
1-2 mm คิดเป็น ________ %
3-4 mm คิดเป็น ________ %
≥5 mm คิดเป็น ________ %
C-5 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Examination Report: ____________________________________________________________________________________________
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BI
PI=___________
C-6 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Radiographic findings:
Technique Teeth Interpretation
Full Mouth Diagnosis : _____________________________________________________________________________________________
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C-7 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
C-8 Charting Form Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Phase of Tx Tx plan CDC2 CDC1 M
Systemic
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Emergency
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Disease
control
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Re-
evaluation
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Corrective
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Maintenance
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C-9 Charting Form Planned Treatment Sequence Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Weeks Planned Treatment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
C-10 Charting Form Treatment Summary Division of General Dentistry, Department of Family and Community Dentistry
CDC2 CDC1 M ชื่อ………………………………………………. HN. ………………..
Student/Date ______________________________________ Instructor/Date __________________________________________
Treatment finished To be continued
Student Name ______________________________________________________ Code ________________________________________
Group__________________ Advisor ______________________________ Prosthodontic Consultant __________________________
Type of patient continue CDC2 CDC1 M
referral to _______________ Details _______________________________________________________________
discharge
Next appointment _________________________________________________________________________________________________